Safety Planning Record

SAFETY PLANNING RECORD

Pursuant to the University of Regina’s Fieldwork Safety Policy, this form, is to be completed by the Project Director and submitted to the Unit Head (or equivalent) prior to the departure on high risk travel and fieldwork. Numerous excursions to the same location or group of locations can be dealt with via one form. The form is good for a single academic year and a new form must be completed annually.

Department: Project Director:

Location of Fieldwork:

Country:

Geographical Site:

Nearest City (name, distance to):

Nature of Research:

Date of Departure: Date of Return:

Fieldwork Team:

In order of Responsible Leadership

Name / Category (check all that apply)
Team
Leader / Participant / Other
(specify) / Trained
First Aider

Hazard Identification – identification of the hazards is critical to ensuring the safety of the Fieldwork Team. The following checklist will provide a guide to identifying common hazards, however, the Project Director should review all aspects of the fieldwork to ensure comprehensive hazard identification has been completed.

Physical Demands - What physical demands will the fieldwork entail?

Climbing / Extreme Heat / Manual lifting, carrying or handling heavy loads
High Altitude / Extreme Cold / Other:

YesNo N/A

Has any participant reported a condition that may require exceptional medical, physical or emergency accommodations? If yes, describe special arrangements and attach to form.
Have arrangements been made to provide participants with:
 Potable water  Personal washing/hygiene  Toilet facilities or procedures
Are participants aware of suitable clothing, footwear and personal supplies required (e.g. boots, hat, raingear, sunglasses, sunscreen, insect repellent)? List required personal supplies and attach to form.
Have arrangements been made to provide participants with, and train them in the safe use of, appropriate personal protective equipment such as:
 Safety Glasses Respiratory Protection Coveralls
 Protective Footwear Protective Headwear Hearing Protection
 Gloves Face Shield Other:
 Knee/shin Guards Flame Retardant Clothing
Are participants familiar with the University of Regina’s policy on the use of alcohol and drugs during field trips?
Are participants familiar with the University of Regina’s policies such as, Health and Safety Policy / Respectful Workplace and Learning Environment Policy / Violence Prevention Policy?

Other Hazards/Protective Measures/Comments:

Working Alone (see University of Regina’s Working Alone Policy)

YesNo N/A

Will any participant be working alone? (See Working Along Policy:
Has an effective communications system been established (e.g. radio, walkie-talkies, phones, whistles, air horns, flares, frequent and scheduled contact)? Describe system:

What other means can be employed to reduce the risk to a participant when working alone?

YesNo N/A

Limitations or prohibitions on certain activities while alone
Provision of emergency supplies
Establishment of minimum training or experience or other standards of competency before working alone
Other:

Other Hazards/Protective Measures/Comments:

Remote Hazardous Areas (see Appendix 3)

What communication systems will be employed?

Cell Phones / Leaving Planned Itinerary at Base Camp / Whistles/Air Horns
Radio or Walkie-Talkies / Leaving Itinerary at Base Camp / Scheduled contacts
Other:

How will participants remain orientated to their location?

Provision of maps / Compass/Map Training / Identification of safest routes
Compass Provision / Local guides / Area familiarization trips
Other:

What procedures have been established in the case participant(s) become lost?

Participant training on remaining at location, use of emergency alarms, use of emergency survival gear
Provision of survival gear
Procedure for organized search
Precautions against fire
Precautions in the event of extreme weather conditions
Other Hazards/Protective Measures/Comments:

Wildlife

YesNo N/A

Have participants been adequately trained in the handling, capture and restraint of study species?
Will participants be administering drugs/anaesthetics or obtaining biological samples?
If so, have they been trained in techniques appropriate to the species and in how to manage disposal of waste or surplus materials?
Have participants been instructed on techniques to avoid unexpected encounters with potentially dangerous wildlife?
What possible diseases may be carried by wildlife in the study area (e.g. rabies, hanta virus)?
Are participants familiar with the methods of contraction of disease from wildlife in the area?
Do the species of study potentially carry zoonosis?

Other Hazards/Protective Measures/Comments:

Chemicals and Hazardous Materials

YesNoN/A

Is each controlled product properly identified with a supplier and workplace label?
Will Material Safety Data Sheets for each controlled product used be readily available to participants?
Do participants have current certification in Workplace Hazardous materials Information System (WHMIS) and Transportation of Dangerous Goods (TDG)?
Will appropriate materials be available to adequately handle hazardous materials, spills, leaks or releases? Describe materials and attach to form.
Will radioisotopes be transported or used in the field? If so, have participants been trained to safely use, store and transport the material in accordance with legal requirements and licence conditions? (see Radiation Safety Policy

Other Hazards/Protective Measures/Comments:

Safe Use of Equipment and Work Processes

YesNoN/A

Are participants trained to operate the equipment safely and in compliance with regulatory standards?
Have employees been trained in safe work procedures?

List Powered or Hazardous Equipment:

List Hazardous Procedures:

Some equipment and processes to which specific regulatory standards apply include:

Chain Saws / Explosives
Compressed Air / Fall Protection above 1.2 metres
Confined Space / Flammable substances
Diving / Ladders
Excavation/Trenching/Tunnelling / Lifting Devices and Hoists
Noise exposure above 85dBAlex / Scaffolds
Powered saws, grinders & planers / Travel on Ice over Water
Powered Mobile Equipment (i.e. roll over protection, seatbelts, competent operators)
Minimum Distances from exposed energized conductors (e.g. power lines)

REQUIREMENTS

Travel Immunization/Prophylaxis Requirements:
Diphtheria
Hepatitis A
Hepatitis B
Japanese Encephalitis
Malaria
Measles
/ Polio
Rabies
Rubella
Tetanus
Typhoid
Yellow Fever
/ Other (specify below):

Equipment

All equipment to be taken on fieldwork must be checked by a qualified person to ensure that it is in good condition, complete and safe(before removal from the campus). Documentation of this pre-trip assessment of the equipment is advised. Individuals operating the equipment must be trained in the proper use of the equipment.

Clothing

Fieldwork participants should be informed of the appropriate clothing to be worn while conducting their work. The appropriate clothing may have to be provided by the University or the worker may have to provide his or her own clothing, depending on requirements.

It should be identified whether or not there is special protective gear to be used while conducting the particular fieldwork and where necessary, this protective clothing must be used and the appropriate training provided in the proper use and maintenance of the personal protective equipment.

When extreme weather conditions can be anticipated or are known, clothing appropriate to the situation should be taken on the fieldwork excursion.

Fieldwork participants must employ common sense in terms of clothing worn on the fieldwork excursion. Participants inappropriately attired or without the correct PPE will not be allowed to participate in the fieldwork.

First-Aid Kits

First-aid kits are required for all off-campus operations. It is the responsibility of the Project Director to provide and ensure that the kit is maintained. Prior to the departure for fieldwork the Project Director is responsible to document the presence of a first-aid kit for the trip and any other required first-aid supplies. Refer to for First Aid Requirements as required by The Occupational Health and Safety Regulations.

(September 2009)1/8

Emergency Preparedness and First Aid

YesNoN/A

Has itinerary been left with responsible person at the University?
Will itinerary be left with responsible local authority?
Are emergency contact numbers for local emergency assistance known?
Are emergency contact numbers for each participant known? List or describe location of list:

(September 2009)1/8

YesNoN/A

Are Saskatchewan Health Insurance Numbers (or equivalent) for each participant available? List or describe location of list:
Is first aid kit complete (see Appendix 12)?
Are all participants familiar with the location of first aid kit and its contents?
Has nearest medical facility been identified? Include Name, Location, & Distance from fieldwork site:
Is a first aid attendant required (see Appendix 12)? Name(s) of attendant(s):
Are additional first aid supplies required? List:
Is there means to summon assistance in case of emergency? Describe:
Are participants familiar with the University of Regina’s Incident Reporting Process? (See Human Resources website under forms)

Other Hazards/Protective Measures/Comments:

EMERGENCY PROCEDURES

Emergency Plan for Research Location: include information on communication, equipment, local emergency contacts, emergency U of R contacts, etc. (attach copy to form)

University Contact and Phone # / Local Contact and Phone #
1. / 1.
2. / 2.
3. / 3.
4. / 4.

Equipment Requirements:

Specialized Clothing – describe: ______
PPE (respirator, eye/face protection/head protection/footwear/high visibility wear) - describe:
______
Training on safe use procedures for power equipment / Additional First Aid or medical supplies
Other training / Emergency supplies
Communication devices (e.g. whistles, 2-way radios) / Vehicle travel survival kit
First Aid kit / Material Safety Data Sheets
First Aid attendant (see Appendix 12) / Maps
Licenses (e.g. vehicle/boat/diving equipment)
Other: ______

RISK ASSESSMENT:

List identified hazards related to activities or environment (i.e. extreme heat or cold, wild animals, endemic disease, firearms, explosives, violence), and chosen available measures for eliminating or reducing risks to acceptable levels:

RISK

PRECAUTIONS TO BE IMPLEMENTED

1.
2.
3.
4.
5.
6.
7.
8.
9.

I, the undersigned, acknowledge that, in keeping with the University of Regina’s Travel and Fieldwork Safety Policy:

(a)I have been fully informed of the risks of this fieldwork and that I accept them;

(b)I am aware of and will comply with the established safety procedures and my duties as a participant as set out in the U of R’s Travel and Fieldwork Safety Policy, including my duty to take reasonable care for my health and safety and the health and safety of others who may be affected by my actions;

(c)I am in a satisfactory state of health to undertake the travel and fieldwork;

(d)I have received all of the prescribed immunizations;

(e)I am aware of limitations of insurance coverage; and

(f)I am aware that I may be subject to academic discipline should I fail to comply with the Travel and Fieldwork Safety Policy and established safety procedures.

ACKNOWLEDGMENT OF PARTICIPANTS:
NAME (print) / SIGNATURE / DATE
1.
2.
3.
4.
5.
6.

(September 2009)1/8

Signature of Project Director

I acknowledge that this safety plan has been prepared in keeping with the requirements of the University of Regina procedures for safety in fieldwork:

______

Name (print)SignatureDate

Signature of Unit Head (or equivalent)

I acknowledge receipt of this document:

______

Name (print)SignatureDate

(September 2009)1/8